Project Summary/Abstract On September 2017 Hurricane Maria hit Puerto Rico (PR), a US territory populated by 3.5 million American citizens. Although the hurricane's effects were varied, one of the most concerning was the total collapse of PR's health care delivery system. The impact of this catastrophe on morbidity, survival, adherence to treatments, and medical complications for individuals living with chronic diseases has yet to be documented. Although disasters are indiscriminate in whom they affect, existing research has shown that poor and disadvantaged populations with pre-existing health disparities bear an unequal amount of the burden during the event's aftermath. The catastrophic collapse of the health care delivery system heightened these disparities as it forced many Puerto Rican patients and health care providers to rely on ad hoc, informal health care arrangements. We are proposing a project that is theoretically informed by an institutional analysis framework in disaster and resilience studies to explore the multilevel ways in which health systems respond to major events such as hurricane Maria. We propose the following aims: Aim 1 ? Systematically document from a multilevel perspective (i.e. institutional, administrative, practical) the collapse of the health care system in PR during and following Hurricane Mara, focusing on the components that failed to respond adequately during and after the emergency. Aim 2 ? Explore the multilevel factors that facilitated institutional resilience within the health care system at the institutional, administrative and practical levels, and determine how these responses varied across geographical areas of the island (i.e., urban vs. rural). Aim 3 ? Describe how patients living with chronic health conditions that need life sustaining treatment (i.e., renal disease, cancer, HIV/AIDS, and opioid addiction) and mental health conditions (i.e., depression, suicidality, trauma/stressor-related disorders, and anxiety) managed their health without regular access to care following hurricane Maria, in order to document post-collapse adaptive capacities, systemic gaps, and health consequences that may not be captured in casualty statistics. We will implement a mixed methods design using institutional ethnographic observation and in-depth qualitative interviews. These techniques will be supplemented in the field with GPS technology, which will later permit formal analysis in Arc-GIS to visualize and address the geographical dimension of our aims. We will carry out institutional ethnographic observation and mapping and qualitative interviews throughout settings that make up PR's health care system. In-depth interviews will be implemented with a theoretically driven sample (Total N=65) of: health policy makers (n=5), health facility administrators (n=10), pharmaceutical supply administrators (n=10), health care professionals (n=20), and patients (n=20). Results will inform the development of emergency planning and preparedness guidelines for the health care systems in PR.